104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately. LRB104 05991 BAB 16024 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately. LRB104 05991 BAB 16024 b LRB104 05991 BAB 16024 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately. LRB104 05991 BAB 16024 b LRB104 05991 BAB 16024 b LRB104 05991 BAB 16024 b A BILL FOR HB1085LRB104 05991 BAB 16024 b HB1085 LRB104 05991 BAB 16024 b HB1085 LRB104 05991 BAB 16024 b 1 AN ACT concerning regulation. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 4 Section 5. The State Employees Group Insurance Act of 1971 5 is amended by changing Section 6.11 as follows: 6 (5 ILCS 375/6.11) 7 Sec. 6.11. Required health benefits; Illinois Insurance 8 Code requirements. The program of health benefits shall 9 provide the post-mastectomy care benefits required to be 10 covered by a policy of accident and health insurance under 11 Section 356t of the Illinois Insurance Code. The program of 12 health benefits shall provide the coverage required under 13 Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 14 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 15 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 16 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 17 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 18 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 19 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 20 356z.70, and 356z.71, 356z.74, 356z.76, 356z.77, and 356z.80 21 of the Illinois Insurance Code. The program of health benefits 22 must comply with Sections 155.22a, 155.37, 355b, 356z.19, 23 370c, and 370c.1, and 370c.3 and Article XXXIIB of the 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately. LRB104 05991 BAB 16024 b LRB104 05991 BAB 16024 b LRB104 05991 BAB 16024 b A BILL FOR 5 ILCS 375/6.11 55 ILCS 5/5-1069.3 65 ILCS 5/10-4-2.3 105 ILCS 5/10-22.3f 215 ILCS 5/370c.3 new 215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 LRB104 05991 BAB 16024 b HB1085 LRB104 05991 BAB 16024 b HB1085- 2 -LRB104 05991 BAB 16024 b HB1085 - 2 - LRB104 05991 BAB 16024 b HB1085 - 2 - LRB104 05991 BAB 16024 b 1 Illinois Insurance Code. The program of health benefits shall 2 provide the coverage required under Section 356m of the 3 Illinois Insurance Code and, for the employees of the State 4 Employee Group Insurance Program only, the coverage as also 5 provided in Section 6.11B of this Act. The Department of 6 Insurance shall enforce the requirements of this Section with 7 respect to Sections 370c, and 370c.1, and 370c.3 of the 8 Illinois Insurance Code; all other requirements of this 9 Section shall be enforced by the Department of Central 10 Management Services. 11 Rulemaking authority to implement Public Act 95-1045, if 12 any, is conditioned on the rules being adopted in accordance 13 with all provisions of the Illinois Administrative Procedure 14 Act and all rules and procedures of the Joint Committee on 15 Administrative Rules; any purported rule not so adopted, for 16 whatever reason, is unauthorized. 17 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 18 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 19 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768, 20 eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 21 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 22 1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84, 23 eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 24 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 25 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751, 26 eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25; HB1085 - 2 - LRB104 05991 BAB 16024 b HB1085- 3 -LRB104 05991 BAB 16024 b HB1085 - 3 - LRB104 05991 BAB 16024 b HB1085 - 3 - LRB104 05991 BAB 16024 b 1 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff. 2 1-1-25; revised 11-26-24.) 3 Section 10. The Counties Code is amended by changing 4 Section 5-1069.3 as follows: 5 (55 ILCS 5/5-1069.3) 6 Sec. 5-1069.3. Required health benefits. If a county, 7 including a home rule county, is a self-insurer for purposes 8 of providing health insurance coverage for its employees, the 9 coverage shall include coverage for the post-mastectomy care 10 benefits required to be covered by a policy of accident and 11 health insurance under Section 356t and the coverage required 12 under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 13 356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 14 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 15 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 16 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 17 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 18 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71, 19 356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code. 20 The coverage shall comply with Sections 155.22a, 355b, 21 356z.19, and 370c, and 370c.3 of the Illinois Insurance Code. 22 The Department of Insurance shall enforce the requirements of 23 this Section. The requirement that health benefits be covered 24 as provided in this Section is an exclusive power and function HB1085 - 3 - LRB104 05991 BAB 16024 b HB1085- 4 -LRB104 05991 BAB 16024 b HB1085 - 4 - LRB104 05991 BAB 16024 b HB1085 - 4 - LRB104 05991 BAB 16024 b 1 of the State and is a denial and limitation under Article VII, 2 Section 6, subsection (h) of the Illinois Constitution. A home 3 rule county to which this Section applies must comply with 4 every provision of this Section. 5 Rulemaking authority to implement Public Act 95-1045, if 6 any, is conditioned on the rules being adopted in accordance 7 with all provisions of the Illinois Administrative Procedure 8 Act and all rules and procedures of the Joint Committee on 9 Administrative Rules; any purported rule not so adopted, for 10 whatever reason, is unauthorized. 11 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 12 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 13 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, 14 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 15 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 16 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, 17 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 18 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. 19 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, 20 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; 21 revised 11-26-24.) 22 Section 15. The Illinois Municipal Code is amended by 23 changing Section 10-4-2.3 as follows: 24 (65 ILCS 5/10-4-2.3) HB1085 - 4 - LRB104 05991 BAB 16024 b HB1085- 5 -LRB104 05991 BAB 16024 b HB1085 - 5 - LRB104 05991 BAB 16024 b HB1085 - 5 - LRB104 05991 BAB 16024 b 1 Sec. 10-4-2.3. Required health benefits. If a 2 municipality, including a home rule municipality, is a 3 self-insurer for purposes of providing health insurance 4 coverage for its employees, the coverage shall include 5 coverage for the post-mastectomy care benefits required to be 6 covered by a policy of accident and health insurance under 7 Section 356t and the coverage required under Sections 356g, 8 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 9 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 10 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26, 11 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 12 356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54, 13 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 14 356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77, 15 and 356z.80 of the Illinois Insurance Code. The coverage shall 16 comply with Sections 155.22a, 355b, 356z.19, and 370c, and 17 370c.3 of the Illinois Insurance Code. The Department of 18 Insurance shall enforce the requirements of this Section. The 19 requirement that health benefits be covered as provided in 20 this is an exclusive power and function of the State and is a 21 denial and limitation under Article VII, Section 6, subsection 22 (h) of the Illinois Constitution. A home rule municipality to 23 which this Section applies must comply with every provision of 24 this Section. 25 Rulemaking authority to implement Public Act 95-1045, if 26 any, is conditioned on the rules being adopted in accordance HB1085 - 5 - LRB104 05991 BAB 16024 b HB1085- 6 -LRB104 05991 BAB 16024 b HB1085 - 6 - LRB104 05991 BAB 16024 b HB1085 - 6 - LRB104 05991 BAB 16024 b 1 with all provisions of the Illinois Administrative Procedure 2 Act and all rules and procedures of the Joint Committee on 3 Administrative Rules; any purported rule not so adopted, for 4 whatever reason, is unauthorized. 5 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 6 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 7 1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731, 8 eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 9 102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 10 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, 11 eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 12 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. 13 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914, 14 eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; 15 revised 11-26-24.) 16 Section 20. The School Code is amended by changing Section 17 10-22.3f as follows: 18 (105 ILCS 5/10-22.3f) 19 Sec. 10-22.3f. Required health benefits. Insurance 20 protection and benefits for employees shall provide the 21 post-mastectomy care benefits required to be covered by a 22 policy of accident and health insurance under Section 356t and 23 the coverage required under Sections 356g, 356g.5, 356g.5-1, 24 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a, HB1085 - 6 - LRB104 05991 BAB 16024 b HB1085- 7 -LRB104 05991 BAB 16024 b HB1085 - 7 - LRB104 05991 BAB 16024 b HB1085 - 7 - LRB104 05991 BAB 16024 b 1 356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14, 2 356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 3 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 4 356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 5 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 6 356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois 7 Insurance Code. Insurance policies shall comply with Section 8 356z.19 of the Illinois Insurance Code. The coverage shall 9 comply with Sections 155.22a, 355b, and 370c, and 370c.3 of 10 the Illinois Insurance Code. The Department of Insurance shall 11 enforce the requirements of this Section. 12 Rulemaking authority to implement Public Act 95-1045, if 13 any, is conditioned on the rules being adopted in accordance 14 with all provisions of the Illinois Administrative Procedure 15 Act and all rules and procedures of the Joint Committee on 16 Administrative Rules; any purported rule not so adopted, for 17 whatever reason, is unauthorized. 18 (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22; 19 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff. 20 1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804, 21 eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 22 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 23 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, 24 eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 25 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 26 7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, HB1085 - 7 - LRB104 05991 BAB 16024 b HB1085- 8 -LRB104 05991 BAB 16024 b HB1085 - 8 - LRB104 05991 BAB 16024 b HB1085 - 8 - LRB104 05991 BAB 16024 b 1 eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.) 2 Section 25. The Illinois Insurance Code is amended by 3 adding Section 370c.3 as follows: 4 (215 ILCS 5/370c.3 new) 5 Sec. 370c.3. Mental health and substance use parity. 6 (a) In this Section: 7 "Application" means a person's or facility's application 8 to become a participating provider with an insurer in at least 9 one of the insurer's provider networks. 10 "Applying provider" means a provider or facility that has 11 submitted a completed application to become a participating 12 provider or facility with an insurer. 13 "Behavioral health trainee" means any person: (1) engaged 14 in the provision of mental health or substance use disorder 15 clinical services as part of that person's supervised course 16 of study while enrolled in a master's or doctoral psychology, 17 social work, counseling, or marriage or family therapy program 18 or as a postdoctoral graduate working toward licensure; and 19 (2) who is working toward clinical State licensure under the 20 clinical supervision of a fully licensed mental health or 21 substance use disorder treatment provider. 22 "Completed application" means a person's or facility's 23 application to become a participating provider that has been 24 submitted to the insurer and includes all the required HB1085 - 8 - LRB104 05991 BAB 16024 b HB1085- 9 -LRB104 05991 BAB 16024 b HB1085 - 9 - LRB104 05991 BAB 16024 b HB1085 - 9 - LRB104 05991 BAB 16024 b 1 information for the application to be considered by the 2 insurer according to the insurer's policies and procedures for 3 verifying a provider's or facility's credentials. 4 "Contracting process" means the process by which a mental 5 health or substance use disorder treatment provider or 6 facility makes a completed application with an insurer to 7 become a participating provider with the insurer until the 8 effective date of a final contract between the provider or 9 facility and the insurer. "Contracting process" includes the 10 process of verifying a provider's credentials. 11 "Participating provider" means any mental health or 12 substance use disorder treatment provider that has a contract 13 to provide mental health or substance use disorder services 14 with an insurer. 15 (b) For all group or individual policies of accident and 16 health insurance or managed care plans that are amended, 17 delivered, issued, or renewed on or after January 1, 2027, or 18 any contracted third party administering the behavioral health 19 benefits for the insurer, reimbursement for in-network mental 20 health and substance use disorder treatment services delivered 21 by Illinois providers and facilities must be equal to or 22 greater than 141% of the Medicare rate for the mental health or 23 substance use disorder service delivered. For services not 24 covered by Medicare, the reimbursement rates must be, on 25 average, equal to or greater than 144% of the insurer's 26 in-network reimbursement rate for such service on the HB1085 - 9 - LRB104 05991 BAB 16024 b HB1085- 10 -LRB104 05991 BAB 16024 b HB1085 - 10 - LRB104 05991 BAB 16024 b HB1085 - 10 - LRB104 05991 BAB 16024 b 1 effective date of this amendatory Act of the 104th General 2 Assembly. This Section applies to all covered office, 3 outpatient, inpatient, and residential mental health and 4 substance use disorder services. If at any time the average 5 reimbursement for in-network medical or surgical services 6 delivered by Illinois providers exceeds 141% of the Medicare 7 rate for such services, then the reimbursement for mental 8 health and substance use disorder treatment services must be 9 equal to or greater than that average. 10 This Section applies to all covered office, outpatient, 11 inpatient, and residential mental health and substance use 12 disorder services. 13 This subsection does not apply to mental health or 14 substance use disorder services provided by a hospital when 15 the hospital has a contract with the insurer that provides for 16 reimbursement for such services based on achieving specified 17 patient health outcomes and other quality measures and 18 includes shared savings from lower health care costs. 19 (c) A group or individual policy of accident and health 20 insurance or managed care plan that is amended, delivered, 21 issued, or renewed on or after January 1, 2026, or contracted 22 third party administering the behavioral health benefits for 23 the insurer, shall cover all medically necessary mental health 24 or substance use disorder services received by the same 25 insured on the same day from the same or different mental 26 health or substance use provider or facility for both HB1085 - 10 - LRB104 05991 BAB 16024 b HB1085- 11 -LRB104 05991 BAB 16024 b HB1085 - 11 - LRB104 05991 BAB 16024 b HB1085 - 11 - LRB104 05991 BAB 16024 b 1 outpatient and inpatient care. 2 (d) A group or individual policy of accident and health 3 insurance or managed care plan that is amended, delivered, 4 issued, or renewed on or after January 1, 2026, or any 5 contracted third party administering the behavioral health 6 benefits for the insurer, shall cover any medically necessary 7 mental health or substance use disorder service provided by a 8 behavioral health trainee when the trainee is working toward 9 clinical State licensure and is under the supervision of a 10 fully licensed mental health or substance use disorder 11 treatment provider, which is a physician licensed to practice 12 medicine in all its branches, licensed clinical psychologist, 13 licensed clinical social worker, licensed clinical 14 professional counselor, licensed marriage and family 15 therapist, licensed speech-language pathologist, or other 16 licensed or certified professional at a program licensed 17 pursuant to the Substance Use Disorder Act who is engaged in 18 treating mental, emotional, nervous, or substance use 19 disorders or conditions. Services provided by the trainee must 20 be billed under the supervising clinician's rendering National 21 Provider Identifier. 22 (e) A group or individual policy of accident and health 23 insurance or managed care plan that is amended, delivered, 24 issued, or renewed on or after January 1, 2026, or any 25 contracted third party administering the behavioral health 26 benefits for the insurer, shall: HB1085 - 11 - LRB104 05991 BAB 16024 b HB1085- 12 -LRB104 05991 BAB 16024 b HB1085 - 12 - LRB104 05991 BAB 16024 b HB1085 - 12 - LRB104 05991 BAB 16024 b 1 (1) cover medically necessary 60-minute psychotherapy 2 billed using the CPT Code 90837 for Individual Therapy; 3 (2) not impose more onerous documentation requirements 4 on the provider than is required for other psychotherapy 5 CPT Codes; and 6 (3) not audit the use of CPT Code 90837 any more 7 frequently than audits for the use of other psychotherapy 8 CPT Codes. 9 (f)(1) Any group or individual policy of accident and 10 health insurance or managed care plan that is amended, 11 delivered, issued, or renewed on or after January 1, 2026, or 12 any contracted third party administering the behavioral health 13 benefits for the insurer, shall complete the contracting 14 process with a mental health or substance use disorder 15 treatment provider or facility for becoming a participating 16 provider in the insurer's network, including the verification 17 of the provider's credentials, within 60 days from the date of 18 a completed application to the insurer to become a 19 participating provider. Nothing in this paragraph (1), 20 however, presumes or establishes a contract between an insurer 21 and a provider. 22 (2) Any group or individual policy of accident and health 23 insurance or managed care plan that is amended, delivered, 24 issued, or renewed on or after January 1, 2026, or any 25 contracted third party administering the behavioral health 26 benefits for the insurer, shall reimburse a participating HB1085 - 12 - LRB104 05991 BAB 16024 b HB1085- 13 -LRB104 05991 BAB 16024 b HB1085 - 13 - LRB104 05991 BAB 16024 b HB1085 - 13 - LRB104 05991 BAB 16024 b 1 mental health or substance use disorder treatment provider or 2 facility at the contracted reimbursement rate for any 3 medically necessary services provided to an insured from the 4 date of submission of the provider's or facility's completed 5 application to become a participating provider with the 6 insurer up to the effective date of the provider's contract. 7 The provider's claims for such services shall be reimbursed 8 only when submitted after the effective date of the provider's 9 contract with the insurer. This paragraph (2) does not apply 10 to a provider that does not have a completed contract with an 11 insurer. If a provider opts to submit claims for medically 12 necessary mental health or substance use disorder services 13 pursuant to this paragraph (2), the provider must notify the 14 insured following submission of the claims to the insurer that 15 the services provided to the insured may be treated as 16 in-network services. 17 (3) Any group or individual policy of accident and health 18 insurance or managed care plan that is amended, delivered, 19 issued, or renewed on or after January 1, 2026, or any 20 contracted third party administering the behavioral health 21 benefits for the insurer, shall cover any medically necessary 22 mental health or substance use disorder service provided by a 23 fully licensed mental health or substance use disorder 24 treatment provider affiliated with a mental health or 25 substance use disorder treatment group practice who has 26 submitted a completed application to become a participating HB1085 - 13 - LRB104 05991 BAB 16024 b HB1085- 14 -LRB104 05991 BAB 16024 b HB1085 - 14 - LRB104 05991 BAB 16024 b HB1085 - 14 - LRB104 05991 BAB 16024 b 1 provider with an insurer who is delivering services under the 2 supervision of another fully licensed participating mental 3 health or substance use disorder treatment provider within the 4 same group practice up to the effective date of the applying 5 provider's contract with the insurer as a participating 6 provider. Services provided by the applying provider must be 7 billed under the supervising licensed provider's rendering 8 National Provider Identifier. 9 (4) Upon request, an insurer, or any contracted third 10 party administering the behavioral health benefits for the 11 insurer, shall provide an applying provider with the insurer's 12 credentialing policies and procedures. An insurer, or any 13 contracted third party administering the behavioral health 14 benefits for the insurer, shall post the following 15 nonproprietary information on its website and make that 16 information available to all applicants: 17 (A) a list of the information required to be included 18 in an application; 19 (B) a checklist of the materials that must be 20 submitted in the credentialing process; and 21 (C) designated contact information of a network 22 representative, including a designated point of contact, 23 an email address, and a telephone number, to which an 24 applicant may address any credentialing inquiries. 25 (g) The Department has the same authority to enforce this 26 Section as it has to enforce compliance with Sections 370c and HB1085 - 14 - LRB104 05991 BAB 16024 b HB1085- 15 -LRB104 05991 BAB 16024 b HB1085 - 15 - LRB104 05991 BAB 16024 b HB1085 - 15 - LRB104 05991 BAB 16024 b 1 370c.1. Additionally, if the Department determines that an 2 insurer or a contracted third party administering the 3 behavioral health benefits for the insurer has violated this 4 Section, the Department shall, after appropriate notice and 5 opportunity for hearing in accordance with Section 402, by 6 order assess a civil penalty of $1,000 for each violation. The 7 Department shall establish any processes or procedures 8 necessary to monitor compliance with this Section. 9 (h) At the end of 5 years, 10 years, and 15 years following 10 the implementation of subsection (b) of this Section, the 11 Department shall review the impact of this Section on network 12 adequacy for mental health and substance use disorder 13 treatment and access to affordable mental health and substance 14 use care. By no later than December 31, 2033, December 31, 15 2038, and December 31, 2043, the Department shall submit a 16 report in each of those years to the General Assembly that 17 includes its analyses and findings. For the purpose of 18 evaluating trends in network adequacy, the Department may 19 examine out-of-network utilization and out-of-pocket costs for 20 insureds for mental health and substance use treatment and 21 services for all plans to compare with in-network utilization. 22 (i) The Department shall adopt any rules necessary to 23 implement this Section by no later than May 1, 2026. 24 (j) This Section does not apply to a health care plan 25 serving Medicaid populations that provides, arranges for, pays 26 for, or reimburses the cost of any health care service for HB1085 - 15 - LRB104 05991 BAB 16024 b HB1085- 16 -LRB104 05991 BAB 16024 b HB1085 - 16 - LRB104 05991 BAB 16024 b HB1085 - 16 - LRB104 05991 BAB 16024 b 1 persons who are enrolled under the Illinois Public Aid Code or 2 under the Children's Health Insurance Program Act. 3 Section 30. The Health Maintenance Organization Act is 4 amended by changing Section 5-3 as follows: 5 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2) 6 (Text of Section before amendment by P.A. 103-808) 7 Sec. 5-3. Insurance Code provisions. 8 (a) Health Maintenance Organizations shall be subject to 9 the provisions of Sections 133, 134, 136, 137, 139, 140, 10 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 11 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 12 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1, 13 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a, 14 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 15 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 16 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25, 17 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33, 18 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40, 19 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47, 20 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55, 21 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62, 22 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69, 23 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77, 24 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b, HB1085 - 16 - LRB104 05991 BAB 16024 b HB1085- 17 -LRB104 05991 BAB 16024 b HB1085 - 17 - LRB104 05991 BAB 16024 b HB1085 - 17 - LRB104 05991 BAB 16024 b 1 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403, 2 403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of 3 subsection (2) of Section 367, and Articles IIA, VIII 1/2, 4 XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the 5 Illinois Insurance Code. 6 (b) For purposes of the Illinois Insurance Code, except 7 for Sections 444 and 444.1 and Articles XIII and XIII 1/2, 8 Health Maintenance Organizations in the following categories 9 are deemed to be "domestic companies": 10 (1) a corporation authorized under the Dental Service 11 Plan Act or the Voluntary Health Services Plans Act; 12 (2) a corporation organized under the laws of this 13 State; or 14 (3) a corporation organized under the laws of another 15 state, 30% or more of the enrollees of which are residents 16 of this State, except a corporation subject to 17 substantially the same requirements in its state of 18 organization as is a "domestic company" under Article VIII 19 1/2 of the Illinois Insurance Code. 20 (c) In considering the merger, consolidation, or other 21 acquisition of control of a Health Maintenance Organization 22 pursuant to Article VIII 1/2 of the Illinois Insurance Code, 23 (1) the Director shall give primary consideration to 24 the continuation of benefits to enrollees and the 25 financial conditions of the acquired Health Maintenance 26 Organization after the merger, consolidation, or other HB1085 - 17 - LRB104 05991 BAB 16024 b HB1085- 18 -LRB104 05991 BAB 16024 b HB1085 - 18 - LRB104 05991 BAB 16024 b HB1085 - 18 - LRB104 05991 BAB 16024 b 1 acquisition of control takes effect; 2 (2)(i) the criteria specified in subsection (1)(b) of 3 Section 131.8 of the Illinois Insurance Code shall not 4 apply and (ii) the Director, in making his determination 5 with respect to the merger, consolidation, or other 6 acquisition of control, need not take into account the 7 effect on competition of the merger, consolidation, or 8 other acquisition of control; 9 (3) the Director shall have the power to require the 10 following information: 11 (A) certification by an independent actuary of the 12 adequacy of the reserves of the Health Maintenance 13 Organization sought to be acquired; 14 (B) pro forma financial statements reflecting the 15 combined balance sheets of the acquiring company and 16 the Health Maintenance Organization sought to be 17 acquired as of the end of the preceding year and as of 18 a date 90 days prior to the acquisition, as well as pro 19 forma financial statements reflecting projected 20 combined operation for a period of 2 years; 21 (C) a pro forma business plan detailing an 22 acquiring party's plans with respect to the operation 23 of the Health Maintenance Organization sought to be 24 acquired for a period of not less than 3 years; and 25 (D) such other information as the Director shall 26 require. HB1085 - 18 - LRB104 05991 BAB 16024 b HB1085- 19 -LRB104 05991 BAB 16024 b HB1085 - 19 - LRB104 05991 BAB 16024 b HB1085 - 19 - LRB104 05991 BAB 16024 b 1 (d) The provisions of Article VIII 1/2 of the Illinois 2 Insurance Code and this Section 5-3 shall apply to the sale by 3 any health maintenance organization of greater than 10% of its 4 enrollee population (including, without limitation, the health 5 maintenance organization's right, title, and interest in and 6 to its health care certificates). 7 (e) In considering any management contract or service 8 agreement subject to Section 141.1 of the Illinois Insurance 9 Code, the Director (i) shall, in addition to the criteria 10 specified in Section 141.2 of the Illinois Insurance Code, 11 take into account the effect of the management contract or 12 service agreement on the continuation of benefits to enrollees 13 and the financial condition of the health maintenance 14 organization to be managed or serviced, and (ii) need not take 15 into account the effect of the management contract or service 16 agreement on competition. 17 (f) Except for small employer groups as defined in the 18 Small Employer Rating, Renewability and Portability Health 19 Insurance Act and except for medicare supplement policies as 20 defined in Section 363 of the Illinois Insurance Code, a 21 Health Maintenance Organization may by contract agree with a 22 group or other enrollment unit to effect refunds or charge 23 additional premiums under the following terms and conditions: 24 (i) the amount of, and other terms and conditions with 25 respect to, the refund or additional premium are set forth 26 in the group or enrollment unit contract agreed in advance HB1085 - 19 - LRB104 05991 BAB 16024 b HB1085- 20 -LRB104 05991 BAB 16024 b HB1085 - 20 - LRB104 05991 BAB 16024 b HB1085 - 20 - LRB104 05991 BAB 16024 b 1 of the period for which a refund is to be paid or 2 additional premium is to be charged (which period shall 3 not be less than one year); and 4 (ii) the amount of the refund or additional premium 5 shall not exceed 20% of the Health Maintenance 6 Organization's profitable or unprofitable experience with 7 respect to the group or other enrollment unit for the 8 period (and, for purposes of a refund or additional 9 premium, the profitable or unprofitable experience shall 10 be calculated taking into account a pro rata share of the 11 Health Maintenance Organization's administrative and 12 marketing expenses, but shall not include any refund to be 13 made or additional premium to be paid pursuant to this 14 subsection (f)). The Health Maintenance Organization and 15 the group or enrollment unit may agree that the profitable 16 or unprofitable experience may be calculated taking into 17 account the refund period and the immediately preceding 2 18 plan years. 19 The Health Maintenance Organization shall include a 20 statement in the evidence of coverage issued to each enrollee 21 describing the possibility of a refund or additional premium, 22 and upon request of any group or enrollment unit, provide to 23 the group or enrollment unit a description of the method used 24 to calculate (1) the Health Maintenance Organization's 25 profitable experience with respect to the group or enrollment 26 unit and the resulting refund to the group or enrollment unit HB1085 - 20 - LRB104 05991 BAB 16024 b HB1085- 21 -LRB104 05991 BAB 16024 b HB1085 - 21 - LRB104 05991 BAB 16024 b HB1085 - 21 - LRB104 05991 BAB 16024 b 1 or (2) the Health Maintenance Organization's unprofitable 2 experience with respect to the group or enrollment unit and 3 the resulting additional premium to be paid by the group or 4 enrollment unit. 5 In no event shall the Illinois Health Maintenance 6 Organization Guaranty Association be liable to pay any 7 contractual obligation of an insolvent organization to pay any 8 refund authorized under this Section. 9 (g) Rulemaking authority to implement Public Act 95-1045, 10 if any, is conditioned on the rules being adopted in 11 accordance with all provisions of the Illinois Administrative 12 Procedure Act and all rules and procedures of the Joint 13 Committee on Administrative Rules; any purported rule not so 14 adopted, for whatever reason, is unauthorized. 15 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; 16 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 17 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, 18 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 19 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 20 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, 21 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 22 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 23 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, 24 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 25 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. 26 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, HB1085 - 21 - LRB104 05991 BAB 16024 b HB1085- 22 -LRB104 05991 BAB 16024 b HB1085 - 22 - LRB104 05991 BAB 16024 b HB1085 - 22 - LRB104 05991 BAB 16024 b 1 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; 2 103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff. 3 1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.) 4 (Text of Section after amendment by P.A. 103-808) 5 Sec. 5-3. Insurance Code provisions. 6 (a) Health Maintenance Organizations shall be subject to 7 the provisions of Sections 133, 134, 136, 137, 139, 140, 8 141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151, 9 152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a, 10 155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g, 11 356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 12 356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 13 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 14 356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 15 356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 16 356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 17 356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 18 356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 19 356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 20 356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 21 356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 22 356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 23 368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 24 401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1, 25 paragraph (c) of subsection (2) of Section 367, and Articles HB1085 - 22 - LRB104 05991 BAB 16024 b HB1085- 23 -LRB104 05991 BAB 16024 b HB1085 - 23 - LRB104 05991 BAB 16024 b HB1085 - 23 - LRB104 05991 BAB 16024 b 1 IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and 2 XXXIIB of the Illinois Insurance Code. 3 (b) For purposes of the Illinois Insurance Code, except 4 for Sections 444 and 444.1 and Articles XIII and XIII 1/2, 5 Health Maintenance Organizations in the following categories 6 are deemed to be "domestic companies": 7 (1) a corporation authorized under the Dental Service 8 Plan Act or the Voluntary Health Services Plans Act; 9 (2) a corporation organized under the laws of this 10 State; or 11 (3) a corporation organized under the laws of another 12 state, 30% or more of the enrollees of which are residents 13 of this State, except a corporation subject to 14 substantially the same requirements in its state of 15 organization as is a "domestic company" under Article VIII 16 1/2 of the Illinois Insurance Code. 17 (c) In considering the merger, consolidation, or other 18 acquisition of control of a Health Maintenance Organization 19 pursuant to Article VIII 1/2 of the Illinois Insurance Code, 20 (1) the Director shall give primary consideration to 21 the continuation of benefits to enrollees and the 22 financial conditions of the acquired Health Maintenance 23 Organization after the merger, consolidation, or other 24 acquisition of control takes effect; 25 (2)(i) the criteria specified in subsection (1)(b) of 26 Section 131.8 of the Illinois Insurance Code shall not HB1085 - 23 - LRB104 05991 BAB 16024 b HB1085- 24 -LRB104 05991 BAB 16024 b HB1085 - 24 - LRB104 05991 BAB 16024 b HB1085 - 24 - LRB104 05991 BAB 16024 b 1 apply and (ii) the Director, in making his determination 2 with respect to the merger, consolidation, or other 3 acquisition of control, need not take into account the 4 effect on competition of the merger, consolidation, or 5 other acquisition of control; 6 (3) the Director shall have the power to require the 7 following information: 8 (A) certification by an independent actuary of the 9 adequacy of the reserves of the Health Maintenance 10 Organization sought to be acquired; 11 (B) pro forma financial statements reflecting the 12 combined balance sheets of the acquiring company and 13 the Health Maintenance Organization sought to be 14 acquired as of the end of the preceding year and as of 15 a date 90 days prior to the acquisition, as well as pro 16 forma financial statements reflecting projected 17 combined operation for a period of 2 years; 18 (C) a pro forma business plan detailing an 19 acquiring party's plans with respect to the operation 20 of the Health Maintenance Organization sought to be 21 acquired for a period of not less than 3 years; and 22 (D) such other information as the Director shall 23 require. 24 (d) The provisions of Article VIII 1/2 of the Illinois 25 Insurance Code and this Section 5-3 shall apply to the sale by 26 any health maintenance organization of greater than 10% of its HB1085 - 24 - LRB104 05991 BAB 16024 b HB1085- 25 -LRB104 05991 BAB 16024 b HB1085 - 25 - LRB104 05991 BAB 16024 b HB1085 - 25 - LRB104 05991 BAB 16024 b 1 enrollee population (including, without limitation, the health 2 maintenance organization's right, title, and interest in and 3 to its health care certificates). 4 (e) In considering any management contract or service 5 agreement subject to Section 141.1 of the Illinois Insurance 6 Code, the Director (i) shall, in addition to the criteria 7 specified in Section 141.2 of the Illinois Insurance Code, 8 take into account the effect of the management contract or 9 service agreement on the continuation of benefits to enrollees 10 and the financial condition of the health maintenance 11 organization to be managed or serviced, and (ii) need not take 12 into account the effect of the management contract or service 13 agreement on competition. 14 (f) Except for small employer groups as defined in the 15 Small Employer Rating, Renewability and Portability Health 16 Insurance Act and except for medicare supplement policies as 17 defined in Section 363 of the Illinois Insurance Code, a 18 Health Maintenance Organization may by contract agree with a 19 group or other enrollment unit to effect refunds or charge 20 additional premiums under the following terms and conditions: 21 (i) the amount of, and other terms and conditions with 22 respect to, the refund or additional premium are set forth 23 in the group or enrollment unit contract agreed in advance 24 of the period for which a refund is to be paid or 25 additional premium is to be charged (which period shall 26 not be less than one year); and HB1085 - 25 - LRB104 05991 BAB 16024 b HB1085- 26 -LRB104 05991 BAB 16024 b HB1085 - 26 - LRB104 05991 BAB 16024 b HB1085 - 26 - LRB104 05991 BAB 16024 b 1 (ii) the amount of the refund or additional premium 2 shall not exceed 20% of the Health Maintenance 3 Organization's profitable or unprofitable experience with 4 respect to the group or other enrollment unit for the 5 period (and, for purposes of a refund or additional 6 premium, the profitable or unprofitable experience shall 7 be calculated taking into account a pro rata share of the 8 Health Maintenance Organization's administrative and 9 marketing expenses, but shall not include any refund to be 10 made or additional premium to be paid pursuant to this 11 subsection (f)). The Health Maintenance Organization and 12 the group or enrollment unit may agree that the profitable 13 or unprofitable experience may be calculated taking into 14 account the refund period and the immediately preceding 2 15 plan years. 16 The Health Maintenance Organization shall include a 17 statement in the evidence of coverage issued to each enrollee 18 describing the possibility of a refund or additional premium, 19 and upon request of any group or enrollment unit, provide to 20 the group or enrollment unit a description of the method used 21 to calculate (1) the Health Maintenance Organization's 22 profitable experience with respect to the group or enrollment 23 unit and the resulting refund to the group or enrollment unit 24 or (2) the Health Maintenance Organization's unprofitable 25 experience with respect to the group or enrollment unit and 26 the resulting additional premium to be paid by the group or HB1085 - 26 - LRB104 05991 BAB 16024 b HB1085- 27 -LRB104 05991 BAB 16024 b HB1085 - 27 - LRB104 05991 BAB 16024 b HB1085 - 27 - LRB104 05991 BAB 16024 b 1 enrollment unit. 2 In no event shall the Illinois Health Maintenance 3 Organization Guaranty Association be liable to pay any 4 contractual obligation of an insolvent organization to pay any 5 refund authorized under this Section. 6 (g) Rulemaking authority to implement Public Act 95-1045, 7 if any, is conditioned on the rules being adopted in 8 accordance with all provisions of the Illinois Administrative 9 Procedure Act and all rules and procedures of the Joint 10 Committee on Administrative Rules; any purported rule not so 11 adopted, for whatever reason, is unauthorized. 12 (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21; 13 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff. 14 1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665, 15 eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22; 16 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 17 1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093, 18 eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 19 103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff. 20 6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445, 21 eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 22 103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff. 23 1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751, 24 eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25; 25 103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff. 26 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised HB1085 - 27 - LRB104 05991 BAB 16024 b HB1085- 28 -LRB104 05991 BAB 16024 b HB1085 - 28 - LRB104 05991 BAB 16024 b HB1085 - 28 - LRB104 05991 BAB 16024 b 1 11-26-24.) 2 Section 95. No acceleration or delay. Where this Act makes 3 changes in a statute that is represented in this Act by text 4 that is not yet or no longer in effect (for example, a Section 5 represented by multiple versions), the use of that text does 6 not accelerate or delay the taking effect of (i) the changes 7 made by this Act or (ii) provisions derived from any other 8 Public Act. HB1085 - 28 - LRB104 05991 BAB 16024 b